Summary: Trans-stomal herniation, where abdominal contents protrude through the stomal aperture and lie between the two intestinal walls of the stom a is a very rare complication of stomas and can resemble a stomal prolapse. We describe a unique case of a stomal prolapse and concurrent trans-stomal small bowel herniation, which required emergency stoma refashioning for incarceration.
Background: Tracheobronchial tree injuries (TBTI) represent a type of trauma that is rare among all trauma patients, with a paucity of literature available in Africa. These may result from blunt or penetrating trauma to the neck and thorax (chest). The purpose of this study was to document the spectrum of injury and the experience with surgical and nonsurgical management and outcome of TBTI in the KwaZulu-Natal setting.
Methods: This was a single-centre retrospective analysis of all patients with TBTI referred to Inkosi Albert Luthuli Central Hospital (IALCH) over 21 years. Data collection extended from 1 January 2003 to 31 December 2023.
Results: Penetrating trauma was the most common cause of injury, with a total of 32 patients (86%), while blunt injuries were seen in five patients (14%). Anatomically, there were 20 cervical tracheal injuries, eight thoracic tracheal injuries, six bronchial injuries and three multiple site injuries. A total of 27 (73%) patients underwent surgery, while 10 (27%) patients were managed conservatively. Overall mortality was seen in four patients and one patient survived with long-term disease sequelae. The overall median duration hospital stay was 6 days (IQR 4-10).
Conclusion: TBTI remains a rare injury. Sepsis was one of the main causes of death in both surgical and conservative management. Conservative management in selected cases is just as effective as definitive surgical management. Overall, there was good outcome with TBTI in this centre.
Summary: We present a rare case of a massive gastrointestinal bleed from a gastrointestinal stromal tumour (GIST) originating from the jejunum. GISTs make up only 0.1-3% of all gastrointestinal neoplasms and typically present as an occult or chronic gastrointestinal bleeding. Acute gastrointestinal bleeding from the small bowel is uncommon and can be a challenging diagnosis to make.
Background: The impact of the SARS-CoV-2 pandemic on emergency surgery services internationally revealed an 87.8% decrease in procedures. The aim of the study was to determine the impact of the pandemic on the number of emergency surgical operations performed at Groote Schuur Hospital, Cape Town, South Africa.
Methods: The study was a retrospective cross-sectional study, comparing the number of emergency operations performed before the pandemic to those performed during the pandemic lockdowns at Groote Schuur Hospital in Cape Town, South Africa. The data were retrieved from the Web Surgibank and Clinicom databases.
Results: The total number of operations performed during the study period (April 2019 - March 2021) was 13 715. The most frequently performed procedure types were orthopaedics (18.6%), hands (16.3%), acute care surgery (16.5%), neurosurgery (10.5%) and trauma (10.1%). There was a 19.5% reduction which was statistically significant (p = 0.002) in the number of surgeries before COVID-19 and during COVID-19. The mean number of operations during the pandemic was less compared to the pre-COVID-19 period (p < 0.001).
Conclusion: COVID-19 significantly impacted the number of operations performed during the pandemic at Groote Schuur Hospital. This overall reduction was less compared to international centres.
Background: Neoadjuvant chemotherapy (NACT) is standard treatment for eligible breast cancer patients. While guidelines recommend combining chemotherapy with trastuzumab for HER2-positive breast cancer, Groote Schuur Hospital is unable to provide trastuzumab due to cost constraints. This study examines the pathological response of breast cancer patients who received NACT, with a particular focus on HER2-positive breast cancer patients who did not receive targeted therapy, trastuzumab, in the neoadjuvant setting.
Methods: A retrospective audit was conducted on patients who received NACT followed by surgery between January 2017 and December 2018 at a tertiary hospital in Cape Town. Data on baseline tumour size, axillary staging, molecular subtype, and treatment response were analysed.
Results: Out of 160 patients, 97.5% were female (n = 156) and 88% underwent mastectomy. Infiltrating ductal carcinoma was the most common histology (94%). Pathological complete response (pCR) was achieved by 21% of patients, and 79% had residual disease. Triple-negative breast cancer showed the best pathological response, with a 31% pCR rate (p < 0.005), while ER-positive/HER2-negative patients had a poor pCR rate of 2.4% (p < 0.005). ER-negative/HER2- positive patients had a 6.7% pCR rate (p = 0.147).
Conclusion: NACT is most effective for triple-negative breast cancer patients, while ER+ve/HER2-ve showed the poorest response. HER2-positive patients, all not receiving trastuzumab, showed a much lower response compared to the international norm when trastuzumab was available. Adding trastuzumab should improve pCR rates for HER2-positive patients.
There has been a sea change in the management of acute appendicitis over the last quarter of a century. This arose from the realisation that with early imaging and clinical scoring systems appendicitis could be diagnosed early and the pathophysiology reversed by the timeous and appropriate administration of intravenous antibiotics. There has been a growing body of literature attesting to the efficacy of antibiotic therapy in the treatment of acute uncomplicated appendicitis.1,2 No less an organisation than the American College of Surgeons has described antibiotic treatment of acute uncomplicated appendicitis as an "accepted first-line therapy."3 The American college came to this conclusion based on a number of randomised trials. Most authors on the topic concur with the college that antibiotic treatment is "not inferior" to appendectomy as based on outcomes, measured up to thirty days.1,2 This has been supported by many clinical audits and reports as well as a number of well-constructed randomised trials.
The movement in the high-income countries of the world away from surgery as the mainstay of treatment for acute uncomplicated appendicitis, has been well documented and is supported both in the literature and by several prominent surgical societies, in both North America and Europe.1,2 The proponents of this approach point to the cost savings associated with reduced use of operating theatres and laparoscopic equipment, as well as the prevention of longterm morbidity such as port site hernias and abdominal adhesions.1,2 They also point to the use of antibiotics as firstline therapy in other abdominal emergencies such as acute diverticulitis. In acute diverticulitis antibiotic therapy may abort acute low-grade inflammation and help avoid surgery, which traditionally involves a morbid stoma. The proponents of non-operative management of acute uncomplicated appendicitis point to the many benefits of this approach. The recent Comparison of Antibiotic Drugs and Appendectomy (CODA) trial which randomised 1 552 adult patients with acute uncomplicated appendicitis, to either laparoscopic appendicectomy or antibiotic therapy, concluded that antibiotics were non-inferior to appendectomy based on results of a standard health-status measure. It should be noted that in the antibiotics group, nearly 3 out of every 10 participants had subsequently undergone an appendectomy by 90 days. Also of note is that patients with an appendicolith were at a higher risk for delayed appendectomy and complications than those without an appendicolith.1,2 The authors went on to state that in the antibiotics group, more than 7 in 10 participants avoided surgery, were treated mostly as outpatients and subsequently missed fewer days at work.
Background: Trauma mortality exhibits three peaks: immediate, early, and late post-traumatic. Early deaths are often due to haemorrhage and central nervous system injury, whereas late deaths are associated with sepsis and multi-organ failure. The neutrophil-lymphocyte ratio (NLR) is a readily available and inexpensive marker of inflammation, and its prognostic value under various conditions has been established. However, the predictive ability of the NLR in trauma mortality remains unclear, with conflicting results from previous studies. This study aimed to investigate the correlation between NLR (on admission and at 48-hour post-admission) and trauma outcomes.
Methods: This retrospective study analysed data of trauma patients (≥ 18 years old) of which 372 were admitted to a level one trauma unit between January and June 2017. The data collected included demographics, mechanism of injury, injury severity score (ISS), new injury severity score (NISS), abbreviated injury scale (AIS), hospital length of stay (LOS), hospital disposition, and NLR values on admission and at 48 hours. Logistic regression models were used to analyse the association between the NLR and mortality, controlling for age, sex, ISS, and AIS. The sample size was calculated based on the anticipated mortality rate and desired power.
Results: The study included 288 patients for admission NLR analysis and 165 patients for the 48-hour NLR analysis. While factors such as ISS, NISS, emergency department (ED) probability of survival, NISS EU probability, and hospital disposition significantly predicted mortality, NLR at both 24 and 48 hours was not significantly associated with mortality. Although NLR showed good diagnostic accuracy, it did not improve the predictive power of the models, including established prognostic factors. The small sample size for 48-hour NLR analysis is a limitation.
Conclusion: Although the NLR is a simple indicator of systemic inflammation, this study found that it does not independently predict mortality in trauma patients when other established prognostic markers are included. These findings suggest that NLR has limited additional prognostic value in this context, highlighting the importance of incorporating established injury severity scores and other clinical factors for accurate mortality risk assessment. Further research with larger sample sizes is needed to confirm these findings and explore the potential role of the NLR in predicting other trauma outcomes.
Background: Vascular injuries are among the causes of preventable death and disabilities. Vascular injuries are observed in both the civilian and combat setting. The vessel injured and mechanism of injury are important considerations prior to the management.
Methods: This was a combined retrospective and prospective study from January 2013 until December 2022 and included patients with vascular trauma requiring trauma-ICU admission. Frequencies and percentages were calculated to summarise categorical data. Median, quartiles and range were calculated to summarise numerical data. Ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the Department of Health.
Results: A total of 2 805 trauma patients were treated by the author's institution over a period of 10 years. From this number, there were 153 (5.5%) patients with vascular injuries who met the criteria to be enrolled in the study. The most commonly injured vessel was the CCA, with a total of 26 (13.5%) and the most common associated injury was bone fractures with a total number of 66 (53.2%). Penetrating trauma accounted for 99 (64.7%) of the cases, which is significantly higher than the blunt trauma component of 54 (35.2%) cases. Of the penetrating injuries 51 (33%) were due to stab wounds, 46 (30%) were due to gunshots, one (0.6%) was due to a bush knife and one (0.6%) due to a bicycle spoke accident.
Conclusion: This study makes an important contribution to the literature because it focuses on the epidemiology of vascular injury only in a subset of patients that are in ICU, whereas most studies focus on all patients. In order to prevent these injuries and associated injuries, the Department of Health with other government departments needs to develop practical and effective preventive measures.
Background: This study aims to determine the cause, spectrum and outcomes of acute fasciotomy for compartment syndrome in a developing world setting. This study serves as an overview of the Pietermaritzburg Metropolitan Trauma Service (PMTS) experience of acute fasciotomy.
Methods: All patients who underwent a fasciotomy between December 2012 and September 2020 were identified from the Hybrid Electronic Medical Registry (HEMR).
Results: During the eight-year period under review, a total of 97 patients required fasciotomy. The mean age was 27.96 years. Of these patients, 88% (85/97) were male and 12% (12/97) were female. There were 57 penetrating injuries, 23 snakebite-related injuries and 17 blunt trauma-related injuries resulting in compartment syndrome requiring fasciotomy. Of these, 52% of injuries involved the lower limb and 47% involved the upper limb, with 1% involving an injury to both upper and lower limbs. The average hospital stay was 12 days, and the mortality rate was 3%.
Conclusion: A broad range of injuries may precipitate acute compartment syndrome (ACS) of the extremity and mandate fasciotomy. Clinicians must actively exclude ACS when managing these conditions. Once identified, ACS requires fasciotomy. In an environment with long prehospital times there seems to be little role for expectant treatment of ACS.
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